Miriam Hospital multidisciplinary team applies sensory protocols to the care of patients with delirium.

Patients with delirium at The Miriam Hospital in Providence can now expect more from their day than lying quietly with a sitter. Thanks to a new sensory protocol, patients with delirium are returning to a normal state much more quickly.

After attending a NICHE conference, Suzanne Brown, OTR-L, learned about new ways to promote movement and action among patients with delirium. In doing subsequent research to develop a curriculum for CNAs, she realized there was no protocol for assessment and treatment, in many cases. She was even more surprised to observe the med/surg unit and see that patients would be in the throes of full-blown delirium before staff modified their environment.

"My colleagues in skilled nursing facilities, acute care hospital and home care were experiencing the same thing," she remarked. "There's just not a lot of literature on managing delirium. Most of what I could find only advised providing glasses and hearing aids and minimizing noise."

While Brown said the medical team was doing a fantastic job of treating the underlying causes of delirium like UTIs or dementia, there was no system for managing the symptoms like agitation, poor concentration, inability to focus, wandering, etc.

Approximately 65 percent of patients at The Miriam Hospital are over age 60, but delirium can affect patients of any age.

Connection to Autism

Brown's "aha moment" occurred when it hit her that children with autism display the exact same warning signs. Together with a multidisciplinary task force, including Martha Watson, MS, RN-BC, GCNS, staff at The Miriam Hospital studied the OT interventions that helped pediatric patients with sensory disorders and tried similar interventions.

OT staff put a $24,000 grant from Lifespan Risk Management to use partially in creating a sensory toolkit and modifying the contents to fit different patient profiles. So, instead of the standard magazines and newspapers, patients had the option of utilizing yarn, squishy balls, fabric, playing cards, crossword puzzles and lavender oil.

As many patients were previously engaging in activities that had no beginning or end (such as rolling blankets or picking at points in the air), items like sandpaper and lambs' wool provided sensory stimulation.

CNAs reported that many patients expressed concern about their money so they experimented with constructing play currency out of paper. Small pocketbooks were created for women fixated on purses.

One lady, a former seamstress, engaged the staff in conversations about fabrics and showed an interest in measuring, so her CNA equipped her with a tape measure. In addition to providing increased stimulation to patients, the initiative also launched reminiscence therapy. The toolkit jumpstarted conversations about the patients' interests and nurses customized their treatment.

"From a nursing perspective, our previous education about delirium focused on medication management so this was a new approach," said Watson. "Our nurses who had autistic children picked up on what we were trying to do right away and made suggestions like using weighted blankets. This was also huge in building a collaborative relationship between nurses and OTs"

Assessing for Hypoactive Delirium

While Watson and Brown expected great success with the patients displaying the signs of hyperactive delirium, they were pleasantly surprised at the positive outcomes for those with hypoactive delirium.

"Our patients in a hypoactive state in critical care reacted very well to the hands on communication and focus on touch," said Watson. "Even many in a medically fragile state began interacting. We had a better understanding of patients' emotions."

According to Watson, hypoactive delirium is often missed because the patient is quiet.

"Many lie in bed and don't say a word," she said. "They don't eat, don't use the bathroom and families always tell us to let them rest.

"But, it could become fatal if the patient is in pain and we don't treat it quickly," she continued. "Sometimes these patients are misdianosed as depressed and we miss the opportunity to treat them."

Watson admits to very "very intolerant" to statements about "pleasantly confused" patients.

"We need to investigate," she said. "Sometimes these patients are confused, sometimes they're constipated. As a team, we need to assess behavior changes."

Positive Results

Catching delirium in an earlier stage can be lifesaving for patients and hospitals can improve their quality indicators as well.

Even something as simple as considering hypoactive delirium as a medical emergency or trying to draw sluggish patients back into reality can help prevent falls or pressure ulcers, Watson said. It also significantly reduces the hospital's use of restraints

Though it's hard to connect the sensory therapy with any quality marker, the popularity of the sensory toolkits in the units and rave reviews from visiting families are evidence enough of the intervention's success. Today, the toolkits are updated as much as finances and infection control regulations allow and the only real challenge is finding the time to train new hires.

"We try to convey a sense of responsibility to the CNAs," said Watson. "We owe it to our patients to modify their activities so we can pull them out of a delirious state. We've seen it happen where we have a permanent effect on the quality of their lives."

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